Abstract

In all areas of medicine physicians are confronted with a myriad ethical problems. It is important that intensivists are well versed on ethical issues that commonly arise in the critical care setting. This chapter will serve to provide a review of common topics, including informed consent, decision-making capacity, and surrogate decision-making. It will also highlight special circumstances related to cardiac surgical critical care, including ethical concerns associated with emerging technologies in cardiac care.

Background

Basic Principles of Medical Ethics

Several decades ago, Beauchamp and Childress described a framework to address ethical issues that arise in medical care (Beauchamp, 1979). It consists of four central principles: beneficence, non-maleficence, autonomy and justice. While there are limitations to relying solely on these four principles to address the range of issues encountered in the care of the critically ill, they do provide a foundation for contemporary medical ethics.

Beneficence

Beneficence is the desire to act in the best interest of the patient. The core of medical practice is the desire to heal or, at the least, to ease the suffering of a patient. Physicians should consider whether treatments and procedures truly offer the potential for benefit, and counter this against any potential for burden. The modern practice of medicine can make this calculation more complex.

Non-Maleficence

The well-known primary principle of the ethical practice of medicine is the admonition by Hippoctrates “primum non nocere” – “first do no harm.” This principle can be especially important when considering highly invasive surgery, such as cardiac surgery. Again, the potential burdens and benefits of the intervention should be fully explored to ensure a reasonable balance,

Autonomy

The principle of autonomy is the right of an individual to govern decisions made about his or her own body. Autonomy is the fundamental groundwork for the informed consent process.

Justice

The principle of justice refers to fairness in the distribution of healthcare resources, as well as respect for the governing laws. Justice is usually invoked when discussing access to treatments that are limited by availability or cost.